Food Shopping Strategies Among a Diverse Sample of East Harlem Residents: A Qualitative Study.

PURPOSE: To inform food retail interventions, this study explored food shopping strategies employed by people constrained by limited budgets but residing in an urban environment offering numerous retail options. APPROACH: Qualitative study incorporating semi-structured interviews and shop-alongs. SETTING: East Harlem, New York City. PARTICIPANTS: 37 East Harlem residents participated in interviews, of whom 15 participated in shop-alongs. METHODS: Interviews and shop-alongs were conducted in English, Spanish, and Mandarin Chinese. Interview transcripts were analyzed using a grounded theory approach. Data from shop-alongs were used to supplement interview findings. RESULTS: Participants shopped 1-2 times at an average of 4 retail locations per week. Two key themes emerged: (1) planning trips and choosing venues; and (2) shopping experiences and perceptions of stores. Price was the primary driver of store choice, followed by product quality and variety. Substantial time was invested in shopping. Most English- and Spanish-speaking participants shopped in East Harlem. Chinese American participants shopped in Chinatown due to language concordance, availability of culturally-preferred foods, and proximity to other services. CONCLUSION: East Harlem residents invested substantial planning, time and effort in food shopping to acquire sufficient food for their households on limited budgets. These findings offer insight into how residents interact with food environments and key drivers of decision-making about food shopping that affect decisions about where to shop and what to purchase.

"Come with us for a week, for a month, and see how much food lasts for you:" A Qualitative Exploration of Food Insecurity in East Harlem, New York City.

BACKGROUND: Food insecurity refers to uncertain access to food on a consistent basis and the stress experienced by families who worry about having sufficient resources to provide balanced meals in their households. Food insecurity has a disproportionate influence on people of color. A robust body of evidence links food insecurity to poor health outcomes. OBJECTIVE: To document experiences of food insecurity among linguistically and ethnically diverse residents of the East Harlem neighborhood of New York City by exploring the ways in which food availability and cost intersect with household budgets, personal preferences, and shopping strategies. DESIGN: In-depth qualitative interviews were conducted with adult residents of New York City's East Harlem neighborhood to provide insights about the links between food insecurity, well-being, and quality of life. PARTICIPANTS/SETTING: Thirty-seven adult residents of East Harlem were recruited through purposive sampling. Eligibility requirements included living in an East Harlem zip code (10029 or 10035); being aged 18 years or older; being the main food shopper and food decision-maker in the household; and speaking English, Spanish, or Mandarin Chinese. The study was conducted from February to May 2018. STATISTICAL ANALYSES PERFORMED: Interviews were analyzed using a grounded theory approach. Codes were organized into broad thematic topics and cross-case analyses were conducted. RESULTS: Participants discussed overall perceptions of food insecurity and seven themes related to the challenges of and strategies for coping with food insecurity: intermittent vs chronic food insecurity, shopping and budgeting strategies, pantries as a vital community resource, social support systems, food insecurity and health, frustration with an unjust system, and pride in "making it work." CONCLUSIONS: To manage food insecurity, many study participants carefully managed food spending, dedicated substantial time to visiting stores and accessing food pantries, and relied on a public benefits cycle that left many without sufficient financial resources at the end of each month.

Changes to the littered cigarette pack environment in New York City between 2011 and 2015.

INTRODUCTION: Imposing policies that increase tobacco prices is a key strategy for reducing smoking prevalence, although it may result in more cigarette trafficking. In 2013, New York City (NYC) passed the Sensible Tobacco Enforcement (STE) law requiring cigarettes be sold for a minimum price of $10.50 per pack. To evaluate whether cigarette price increases changed patterns of behaviour related to cigarette tax evasion, we examined littered pack study data from 2011 and 2015. METHODS: Littered cigarette packs were collected from a random sample of NYC census tracts in 2011 and 2015. The proportions of cigarette packs with proper local, known non-local, foreign or unknown, and no tax stamp were calculated. Changes in volume, source and consumption of domestically trafficked cigarettes over time were estimated. RESULTS: In 2011, 255 packs with cellophane were collected; in 2015, 226 packs with cellophane were collected. Packs without proper local stamp increased from 60.7% in 2011 to 76.3% in 2015 (p<0.05) and those with foreign or unknown stamp increased from 11.6% in 2011 to 31.4% in 2015 (p<0.05). The percentage of domestically sourced packs attributed to domestic trafficking increased significantly from a range of 47.9% to 52.8% in 2011 to a range of 59.4% to 63.2% in 2015. CONCLUSION: While the trafficking rate among domestically sourced cigarettes increased between 2011 and 2015 (before and after the STE minimum price floor on cigarette packs was in place), there was a decline in total consumption of domestically trafficked cigarettes due to a significant increase in consumption of foreign-sourced cigarettes. Jurisdictions considering price measures should bolster monitoring and enforcement efforts to maximise public health impact. Given the interstate nature of cigarette trafficking in the USA, Federal intervention would be optimal.

Smoking Social Norms Among Young Adults in New York City.

More than half of young adult (YA) (ages 18-26) smokers are non-daily smokers. While standard cessation methods are generally successful with adults and daily smokers, there is evidence that they are not as successful among non-daily smokers or young adults. Additionally, YA smokers are also in a transition period to regular smoking, making research on understanding how interpersonal and environmental factors affect this group of smokers critical. Randomized time location sampling was used to create a sample of New York City YA bar patrons between June and November 2013, who completed a self-administered survey (1,916 surveys). Questions were asked about perceived smoking social norms, stigma, behaviors, and demographics. Overall, almost half of the YA reported being current smokers (44.1%); one-third were non-daily smokers (36.7%) and less than ten percent were daily smokers (7.4%). Non-daily smokers compared with daily smokers had greater odds of believing New Yorkers disapproved of smoking [adjusted odds ratio (ORadj 1.76, 95 % CI 1.10-2.79)], keeping tobacco a secret from certain people (ORadj 1.84, 1.14-2.96) and feeling guilty when smoking (ORadj: 2.54; 1.45-4.45). Non-daily smokers had 41% lower odds of reporting how people who are important to you disapproved of smoking than daily smokers (ORadj: 0.59; 0.38-0.94). Further studies of interpersonal/environmental factors among YA smokers may support modifications to cessation programs that result in more successful YA quit attempts.

Lessons learned from the development and implementation of a citywide stair prompt initiative.

Stair climbing is a readily available form of vigorous-intensity physical activity. Evidence indicates that placing stair prompt signs at points-of-decision (e.g. near elevators and stairways) is an inexpensive, effective strategy for increasing physical activity through stair use. This article aims to share the experience of the New York City Department of Health and Mental Hygiene (NYC DOHMH) in the outreach and implementation of a population-scale stair prompt initiative, including lessons learned from process evaluations, with other public health authorities conducting a similar program. Between May 2008 and August 2012, NYC DOHMH implemented a stair prompt initiative as one strategy in a comprehensive program to increase physical activity and healthy eating through physical improvements to NYC's buildings, streets and neighborhoods, particularly targeting facilities in underserved and low-income neighborhoods. Program evaluation was conducted using program planning documents to examine the process, and data from NYC information line call center, outreach tracking database, and site and phone audits to examine process outcomes. The initiative successfully distributed more than 30,000 stair prompts to building owners/managers of over 1000 buildings. Keys to success included multi-sector partnerships between NYC's Health Department and non-health government agencies and organizations (such as architecture and real estate organizations), a designated outreach coordinator, and outreach strategies targeting building owners/managers owning/managing multiple buildings and buildings serving underserved and at risk populations. A NYC citywide initiative successfully distributed stair prompts to the wider community to promote population-level health impacts; lessons learned may assist other jurisdictions considering similar initiatives to increase physical activity.

Opportunities and Challenges in Precision Medicine: Improving Cancer Prevention and Treatment for Asian Americans.

Cancer is the leading cause of death among Asian Americans, and cancer cases among Asian Americans, Pacific Islanders, and Native Americans are expected to rise by 132% by 2050. Yet, little is known about biologic and environmental factors that contribute to these higher rates of disease in this population. Precision medicine has the potential to contribute to a more comprehensive understanding of morbidity and mortality trends among Asian American subgroups and to reduce cancer-related health disparities by recognizing patients as individuals with unique genetic, environmental, and lifestyle characteristics; identifying ways in which these differences impact cancer expression; and developing tailored disease prevention and clinical treatment strategies to address them. Yet, substantial barriers to the recruitment and retention of Asian Americans in cancer research persist, threatening the success of precision medicine research in addressing these knowledge gaps. This commentary outlines the major challenges to recruiting and retaining Asian Americans in cancer trials, suggests ways of surmounting them, and offers recommendations to ensure that personalized medicine becomes a reality for all Americans.

An electromechanical, patient positioning system for head and neck radiotherapy.

In cancer treatment with radiation, accurate patient setup is critical for proper dose delivery. Improper arrangement can lead to disease recurrence, permanent organ damage, or lack of disease control. While current immobilization equipment often helps for patient positioning, manual adjustment is required, involving iterative, time-consuming steps. Here, we present an electromechanical robotic system for improving patient setup in radiotherapy, specifically targeting head and neck cancer. This positioning system offers six degrees of freedom for a variety of applications in radiation oncology. An analytical calculation of inverse kinematics serves as fundamental criteria to design the system. Computational mechanical modeling and experimental study of radiotherapy compatibility and x-ray-based imaging demonstrates the device feasibility and reliability to be used in radiotherapy. An absolute positioning accuracy test in a clinical treatment room supports the clinical feasibility of the system.

A national survey of facilities for complainants of sexual assault.

In 2006, a national survey demonstrated wide disparities in services offered to sexual assault complainants in the UK, most marked between sexual assault referral centres and non-sexual assault referral centres (police victim examination suites). With national standards introduced in 2009 and the expansion of sexual assault referral centres, we aimed to evaluate the current situation. A questionnaire based on the original 2006 survey, collecting data on population covered, access, funding, personnel, medical care and clinical governance was sent to all 44 UK sexual assault referral centres open in 2012. No non-sexual assault referral centres were identified. Data were collected over six months from December 2012. Twenty-three sexual assault referral centres from England and Scotland responded (response rate 52%), but not all answered every question. All (20/20) had 24 h access for acute referrals, although one sexual assault referral centre reported 24 h opening was not always possible due to recruitment issues. Thirteen of 20 (65%) had a separate rota for under 16 s, but this was often not 24 h/day. All services (20/20) offered facilities for non-police referrals and for provision of anonymous intelligence. All sexual assault referral centres employed female examiners, 11/17 (65%) male examiners and half (10/20) forensic nurse practitioners. All (21/21) offered pregnancy testing and emergency contraception, 19/21 (90%) HIV post-exposure prophylaxis , 12/21 (57%) hepatitis B virus vaccine and 11/21 (52%) medical care for injuries on site. For follow-up care, 12/21 (57%) provided in house counselling, 10/21 (48%) sexually transmitted infection screening, 12/21 (57%) hepatitis B virus vaccination and 14/21 (67%) HIV post-exposure prophylaxis . Our survey shows improvement in services for complainants of sexual assault since 2006 with better access to forensic examinations, medical and psychological care. However, as the response rate was low and without data from non-sexual assault referral centre services, we cannot give a comprehensive national picture. Our results also show that there has been little improvement in providing sexual health screening on site or by referral and this should be addressed by sexual assault referral centres.

Development of Culturally Appropriate Support Strategies to Increase Uptake of Nicotine Replacement Therapy Among Russian- and Chinese-Speaking Smokers in New York City.

Approximately 80,000 New York City smokers are Chinese or Russian speakers. To increase utilization of smoking cessation services among these populations, the Department of Health and Mental Hygiene developed linguistically and culturally tailored outreach strategies to promote and enhance its annual Nicotine Patch and Gum Program. In 2010, online web applications in Chinese and Russian were introduced. In 2011, input was sought from the community to develop Russian-language radio and newspaper ads, and a Russian-speaking liaison provided phone-assisted online enrollment support. In 2012, Chinese newspaper ads were introduced, and a Cantonese- and Mandarin-speaking liaison was hired to provide enrollment support. In 2010, 51 Russian speakers and 40 Chinese speakers enrolled in the program via web application. In 2011, 510 Russian speakers applied via the web application, with 463 assisted by the Russian-speaking liaison; forty-four Chinese speakers applied online. In 2012, 394 Russian speakers applied via the web application; 363 were assisted by the Russian-speaking liaison. Eighty-five Chinese smokers applied online via the web application; seventy were assisted by the Chinese-speaking liaison. Following the implementation of culturally tailored cessation support interventions, ethnic Russian smokers' uptake of cessation support increased tenfold, while Chinese smokers' uptake doubled. Although linguistically appropriate resources are an essential foundation for reaching immigrant communities with high smoking rates, devising culturally tailored strategies to increase quit rates is critical to programmatic success.

Point-of-Sale Tobacco Marketing to Youth in New York State.

PURPOSE: To assess youth exposure to menthol versus nonmenthol cigarette advertising, we examined whether menthol cigarette promotions are more likely in neighborhoods with relatively high youth populations. METHODS: We linked 2011 New York State Retail Advertising Tobacco Survey observational data with U.S. Census and American Community Survey demographic data. Multivariable models assessed the relationship between neighborhood youth population and point-of-sale cigarette promotions for three brands of cigarettes, adjusting for neighborhood demographic characteristics including race/ethnicity and poverty. RESULTS: Menthol cigarette point-of-sale marketing was more likely in neighborhoods with higher proportions of youth, adjusting for presence of nonmenthol brand marketing, neighborhood race/ethnicity, neighborhood poverty, and urban geography. CONCLUSIONS: Data from the 2011 Retail Advertising Tobacco Study linked to block level census data clearly indicate that price reduction promotions for menthol cigarettes are disproportionately targeted to youth markets in New York State.

Evaluation of the Farmers' Markets for Kids programme.

OBJECTIVE: To assess the impact of Farmers' Markets for Kids, a farmers' market-based, child-oriented nutrition education programme, on attitudes and behaviours related to preparing and consuming produce among child participants and their caregivers in New York City (NYC). DESIGN: Retrospective pre-test/post-test cross-sectional survey with caregivers of children participating in Farmers' Markets for Kids classes. SETTING: Four NYC farmers' markets where Farmers' Markets for Kids classes are implemented; these markets serve low-income communities. SUBJECTS: Two hundred and twelve adult caregivers of children who participated in Farmers' Markets for Kids classes. RESULTS: Caregivers reported that children's consumption of fruits and vegetables had increased since participating in Farmers' Markets for Kids and that their children more frequently assisted with food preparation; both of these improvements were statistically significant. Caregivers also reported significant improvements in attitudes: since participating in Farmers' Markets for Kids, their children were more willing to try new fruits and vegetables and caregivers found it easier to prepare fruits and vegetables for their children. Almost all respondents (99 %) reported purchasing more fruits and vegetables since participating in Farmers' Markets for Kids and 95 % had prepared the programme's recipes at home. CONCLUSIONS: Findings suggest that Farmers' Markets for Kids may be an effective approach for increasing produce consumption among participating children and improving related attitudes among children and caregivers. This evaluation provides support for future efforts to undertake more rigorous evaluations of such programmes.

Commentary: Persistence and Health-Related Consequences of the Model Minority Stereotype for Asian Americans.

Fifty years ago, the term model minority was coined to describe the extraordinary ability of Asian Americans to overcome hardship to succeed in American society. Less well-known is how the model minority stereotype was cultivated within the context of Black-White race relations during the second half of the 20th century, and how this stereotype, in turn, has contributed to the understanding and prioritization of health disparities experienced by Asian Americans. The objectives of this article are to define the model minority stereotype, present its controversies, and provide examples of its social and health-related consequences (ie, implications for obesity and tobacco) across multiple levels of society and institutions. A salient theme throughout the examples provided is the limitation of data presented at the aggregate level across all Asian subgroups which masks meaningful disparities. The intent is to increase the visibility of Asian Americans as a racial/ethnic minority group experiencing chronic disease health disparities and deserving of health-related resources and consideration.

Going tobacco-free on 24 New York City university campuses: A public health agency's partnership with a large urban public university system.

The New York City Department of Health and Mental Hygiene partnered with the nation's largest university system, the City University of New York (CUNY), to provide technical assistance and resources to support the development and implementation of a system-wide tobacco-free policy. This effort formed one component of Healthy CUNY-a larger initiative to support health promotion and disease prevention across the university system and resulted in the successful introduction of a system-wide tobacco-free policy on all CUNY campuses. Glassman et al (J Am Coll Health. 2011;59:764-768) published a blueprint for action related to tobacco policies that informed our work. This paper describes the policy development and implementation process and presents lessons learned from the perspective of the Health Department, as a practical case study to inform and support other health departments who may be supporting colleges and universities to become tobacco-free.

A Mixed-Methods Evaluation of a SNAP-Ed Farmers' Market-Based Nutrition Education Program.

OBJECTIVE: Evaluate the effectiveness of the Stellar Farmers' Market program. DESIGN: Mixed methods including focus groups and a quasi-experiment comparing a control group of market shoppers who had never attended a class, participants attending 1 class, and participants attending ≥ 2 classes. SETTING: Eighteen farmers' markets in New York City. PARTICIPANTS: A total of 2,063 survey respondents; 47 focus group participants. INTERVENTION: Farmers' market-based nutrition education and cooking classes paired with vouchers for fresh produce. MAIN OUTCOME MEASURES: Attitudes, self-efficacy, and behaviors regarding fruit and vegetable (FV) preparation and consumption. ANALYSIS: Bivariate and regression analysis examined differences in outcomes as a function of number of classes attended. Qualitative analysis based on a grounded theory approach. RESULTS: Attending ≥ 1 classes was associated with more positive attitudes toward consuming FV; attending ≥ 2 classes was associated with greater FV consumption and higher self-efficacy to prepare and consume produce. Respondents attending ≥ 2 classes consumed almost one-half cup more FV daily than others. These associations remained after controlling for age, race/ethnicity, education, and gender. CONCLUSIONS AND IMPLICATIONS: Offering nutrition education and cooking classes at farmers' markets may contribute to improving attitudes, self-efficacy, and behaviors regarding produce preparation and consumption in low-income populations.

Increasing access to fruits and vegetables: perspectives from the New York City experience.

Broad recognition now exists that price, availability, and other structural factors are meaningful barriers to fruit and vegetable consumption, particularly among low-income adults. Beginning in 2005, the New York City Department of Health and Mental Hygiene used the social-ecological model to develop a multifaceted effort to increase fruit and vegetable access citywide, with emphasis in low-income neighborhoods. Overall, the percentage of New York City adults who reported consuming no fruits and vegetables in the previous day decreased slightly over a 10-year period (2002: 14.3% [95% confidence interval = 13.4%, 15.2%]; 2012: 12.5% [95% confidence interval = 11.4%, 13.6%]; P for trend < .001). Our approach hypothesizes that complementary initiatives, implemented simultaneously, will create a citywide food environment that fuels changes in social norms and cultural preferences, increases consumer demand, and supports sustainable access to affordable produce.

The impact of a temporary recurrent street closure on physical activity in New York City.

At least 70 US cities have now introduced ciclovías-large-scale street closures to promote physical activity-joining numerous other cities worldwide that have implemented ciclovías in efforts to improve population health. We assessed the impact of Summer Streets, a New York City program in which 6.9 contiguous miles of urban streets were closed to traffic and opened for walking, cycling, and group activities, such as dancing and yoga, on population physical activity levels. Screen line counts were used to estimate attendance, and a street intercept survey was conducted to assess demographic characteristics of participants, baseline adherence to physical activity recommendations, and type and duration of physical activity at Summer Streets. In addition, a traffic study was used to determine if there were vehicular traffic delays as a result of the program. About 50,000 people participated in Summer Streets; among participating New Yorkers, bicyclists averaged 6.7 miles, runners 4.3 miles, and walkers 3.6 miles, equivalent to 72-86 min of moderate physical activity. Among New Yorkers attending Summer Streets, 24 % reported that they did not routinely engage in moderate- or vigorous-intensity physical activity. These non-routine exercisers engaged in the equivalent of 26-68 min of moderate-intensity physical activity at Summer Streets. Summer Streets served as an enticement for New Yorkers, including those who did not ordinarily meet physical activity recommendations, to engage in physical activity. There were no significant vehicular traffic delays during the program.

Evaluation of the New York City Green Carts program.

Access to fresh fruits and vegetables is a concern, particularly among low-income populations. Mobile vending is one strategy to expand produce availability and access to increase consumption. In 2008, New York City launched a mobile vending initiative, Green Carts. We report on the evaluation. Three waves of cross-sectional observational surveys of produce availability, variety, and quality were conducted during the summers of 2008, 2009, and 2011 in a stratified random sample of stores and carts comparing establishments in Green Cart neighborhoods (n = 13) with comparison neighborhoods (n = 3). Bivariate analyses for availability, variety, and quality comparing Green Cart and comparison neighborhoods were presented across years, and logistic and negative binomial regressions were used to test whether fruit and vegetable availability, variety, and quality increased in Green Cart compared with comparison neighborhoods, adjusting for clustering and neighborhood demographics. Establishments selling fruits and vegetables in Green Cart neighborhoods increased between 2008 and 2011 (50% to 69%, p <0.0001); there was no comparable increase in comparison neighborhoods. Establishments selling more than 10 fruits and vegetables types increased from 31% to 38% (p = 0.0414) in Green Cart neighborhoods; there was no change in comparison neighborhoods. Produce quality was high among comparison establishments, with 95% and 94% meeting the quality threshold in 2008 and 2011, while declining in Green Cart neighborhood establishments from 96% to 88% (p < 0.0001). Sustained produce availability was found in Green Cart neighborhoods between 2008-2011. Green Carts are one strategy contributing to improving produce access among New Yorkers.

Designing a quality improvement program with electronic health records: New York City's Health eQuits.

Despite clear recommendations for identifying and intervening with smokers, clinical preventive practice is inconsistent in primary care. Use of electronic health records could facilitate improvement. Community health centers treating low-income and Medicaid recipients with greater smoking prevalence than the general population were recruited for a pilot program. Key design elements used to engage centers' participation include designating a project champion at each organization, confirming ability to transmit data for reporting and participation, and offering money to facilitate initial engagement; however, financial incentives did not motivate all organizations. Other methods to elicit participation and to motivate practice change included building on centers' previous experiences with similar programs, utilizing existing relationships with state cessation centers, and harnessing the "competitive" spirit-sharing both good news and areas for improvement to stimulate action. These experiences and observations may assist others in designing programs to improve clinical interventions with smokers.

Institution-to-institution mentoring to build capacity in 24 local US health departments: best practices and lessons learned.

INTRODUCTION: Institutional mentoring may be a useful capacity-building model to support local health departments facing public health challenges. The New York City Department of Health and Mental Hygiene conducted a qualitative evaluation of an institutional mentoring program designed to increase capacity of health departments seeking to address chronic disease prevention. The mentoring program included 2 program models, a one-to-one model and a collaborative model, developed and implemented for 24 Communities Putting Prevention to Work grantee communities nationwide. METHODS: We conducted semi-structured telephone interviews to assess grantees' perspectives on the effectiveness of the mentoring program in supporting their work. Two interviews were conducted with key informants from each participating community. Three evaluators coded and analyzed data using ATLAS.ti software and using grounded theory to identify emerging themes. RESULTS: We completed 90 interviews with 44 mentees. We identified 7 key program strengths: learning from the New York City health department's experience, adapting resources to local needs, incorporating new approaches and sharing strategies, developing the mentor-mentee relationship, creating momentum for action, establishing regular communication, and encouraging peer interaction. CONCLUSION: Participants overwhelmingly indicated that the mentoring program's key strengths improved their capacity to address chronic disease prevention in their communities. We recommend dissemination of the results achieved, emphasizing the need to adapt the institutional mentoring model to local needs to achieve successful outcomes. We also recommend future research to consider whether a hybrid programmatic model that includes regular one-on-one communication and in-person conferences could be used as a standard framework for institutional mentoring.